Hegedus EJ. Br J Sports Med. 2012 July 7. [Epub ahead of print] Link to abstract: https://www.ncbi.nlm.nih.gov/pubmed/22773322
One of the barriers for many clinicians with implementing evidence-based practice is sifting through and digesting the number and variety of studies in the literature. SMR has previously posted on clinical tests for SLAP lesions and a new study by Hegedus (2012) provides a detailed systematic review and meta-analysis of not just SLAP lesion tests but other special tests for the shoulder as well. It is these types of studies that provide a framework for not only the practicing clinician but also for educating students on which tests truly provide the ability to rule in/out pathology. Hegedus et al 2008previously examined several special tests at the shoulder and this study served as an update. The purpose of this study was to examine the evidence for special tests related to shoulder injuries and to determine their usefulness in adult patients. The author utilized similar methods from the previous study but the search results were restricted to literature published from November 2006 to February 2012. A non-date restricted search was also completed to include two additional databases: Embase and the Cochrane Library. From this effort, 1,766 articles and abstracts were initially identified for inclusion; however, duplicates and those not appropriate for the intention of the meta-analysis were excluded resulting in 65 articles and abstracts. Further review of full text articles for appropriateness left 22 articles. The authors added 10 that were from the authors’ private collections. The remaining thirty-two new articles, in addition to ones compiled from the previous attempt, were reviewed using the Quality Assessment of Diagnostic Accuracy Studies, Version 2 (QUADAS 2) tool which determined the bias and applicability of each paper. Results indicated that the Hawkins-Kennedy test demonstrates the ability to rule out subacromial impingement when the test is negative but the negative likelihood ratio was poor. Yeargson’s test, when used to detect SLAP lesion, initially demonstrated high specificity but the sensitivity was low. The apprehension, relocation, and surprise for anterior instability were the only tests to demonstrate clinical utility in ruling out the pathology. A number of other tests (posterior apprehension for posterior instability, passive distraction test for SLAP lesion, AC resisted extension, resisted belly press and coracoid palpation to name a few) showed promising results with high specificity and sensitivity and the authors note that further investigation is needed on these tests.
Assessing the impact of evidence-based studies such as this goes beyond attempting to answer the question “which test is the best?”. In fact, based on the data collected through this study, is it not possible to recommend a single test for a particular pathology. This is a direct reflection of the complex nature of most shoulder injuries as its large range of motion compounds the evaluation process. Shoulder impingement, for example, rarely involves one single structure and is often secondary to scapular or glenohumeral stability. A clinician often performs several special tests to determine its presence. Results of this study did demonstrate that a number of tests appear worthy of further investigation in their ability to determine the presence of pathology at the shoulder and furthermore, which tests do not demonstrate utility to a clinician. How do you, as a clinician, use information from studies such as this? Do you modify the tests you utilize in an exam based on evidence-based results? Or do you continue to use what is best in your hands?
Written By: Laura McDonald
Reviewed by: Stephen Thomas
Related posts:Hegedus EJ (2012). Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. British journal of sports medicine PMID: 22773322